Pain is real to patient and provider when empathy is present

Pain Medicine, Virtual Issue: Pain Education

Pain Medicine is a multi-disciplinary journal dedicated to pain clinicians, educators and researchers with an interest in pain from various medical specialties. This scholarly, indexed publication reflects the rapid growth in pain science and practice as well as the field's need for policy, ethical, and forensic commentary on pain and its management.

“Of pain you could wish only one thing: that it should stop. Nothing in the world was so bad as physical pain. In the face of pain there are no heroes.”

― George Orwell, 1984

In 2004, the World Health Organization in cooperation with the International Association for the Study of Pain (IASP) and the European Federation of IASP Chapters (EFIC) announced the first Global Day Against Pain. The culmination of over 30 years of effort to acknowledge the major role of pain in human experience and the need to recognize that “Pain is real” and “Pain relief is a human right”.

Fourteen years later, pain plagues a billion or more globally, and pain-associated conditions, including low back pain and headache, cause more years lost to disability than any other illness group. In addition to wide variability in access to basic pain care and treatment, troubling disparities exist between countries where opioids are so scarce that a person with advanced cancer faces an agonizing death, and countries where opioids are so accessible that a generation is decimated by overdose deaths.

Biologically, pain is a sophisticated aspect of sentient corporeal existence: evolved to defend living beings from inadvertent harm, pain results in decreased biological fitness both in excess and deficit. Foremost, the pain system is a deeply ingrained protective system necessary for flourishing and survival. Those with absent pain perception will experience recurrent wounding and shortened life-spans. By contrast, those with excessive pain perception suffer harm, their internal experience makes social engagement and productive life impossible. Severe pain causes ruinous suffering so that healthcare providers must attend to the deeper dimensions of pain, not failing to provide treatments that are timely, safe, and cost-effective. Because pain is complex and distinguishing ‘superfluous’ pain from ‘sentinel’ pain requires cautious discernment, the clinical challenge of pain is compelling; unfortunately most health professionals receive only minimal formal training in pain management.

For decades, pain has been dismissed by the privileged and pain-free as ‘subjective’ and still today efforts continue to identify the objective measure of pain. Even once visualized on a computer screen however, pain will remain an intensely personal experience. One person can only understand another’s experience by dint of conscientious effort. It is time to dispense with calling pain subjective, it is not; It is intersubjective. Developed by philosophers to communicate the idea that one person’s internal experience could be understood by an observer under certain conditions, one of those being empathy, intersubjectivity is a far more appropriate term to describe pain as we understand it today. To declare pain ‘subjective’ perpetuates outdated and inhumane misconceptions, reflecting persistent denial of empathy combined with slow diffusion of knowledge. What is empathy? Listening to others when they tell us about their experiences; with compassion, we respond to alleviate pain.

I recently saw a patient I first met three years ago when she was seeking treatment for intractable severe headaches. The headaches had started during a medical procedure and her symptoms were initially dismissed. She endured years of pain as doctor after doctor minimized the pain or proposed stop-gap solutions. She was frustrated by health system failures and contemplating litigation. Over several meetings, we worked together and developed a comprehensive treatment plan for her headaches, adopting solutions based on her preferences and inclinations. The treatment required a lot of effort on her part and tolerant sensitivity on mine. We settled on combining a low-dose pain-active antidepressant with daily transcutaneous electrical nerve stimulation, a physical therapy-based home exercise program, activity modification, and sleep hygiene as well as non-opioid rescue medication. The patient learned a lot about her condition and was now in charge of her pain management. The critical step on her journey was to find a trained practitioner to listen to her and accept her pain without judgment: someone prepared to learn about her life, her values, her personality, and her pain; ready to explore the options for self-management, and take time to discover what that pain was telling us both.

At the national and global levels, the situation appears quite dire, although there are glimmers of hope: 1) Highly motivated individuals are constantly pushing for change: the IASP has declared a Global Year for Excellence in Pain Education, local pain societies hold annual meetings, patient-based pain organizations offer support, and local pain champions advocate for improved education. 2) Progress toward understanding the need to prepare healthcare providers to understand and address pain continues with validated curricula in pain, teaching materials such as the NIH Pain Consortium Centers of Excellence in Pain Education (CoEPEs), EFIC teaching programs, and expert-defined competencies to ensure licensure-level preparation in pain. 3) There are spontaneous efforts around the world to innovate more effective ways to convey pain knowledge and instantiate competency in pain care such as the IASP Developing Countries grant program and Interprofessional Pain Competencies initiative.

Once the ‘lightbulb’ goes on and policymakers and stakeholders recognize the value of pain management, change will follow. The pain champions are ready, won’t you join us?

Dr. Beth B. Hogans, an Associate Professor of Neurology and Director of Pain Education at Johns Hopkins School of Medicine, is interim Associated Director of Education and Evaluation at the Baltimore Veterans Administration Geriatric Research Education and Clinical Center and editor of the Pain Education and Training section of Pain Medicine. Dr. Hogans is a member of the executive task force for the 2018 IASP Global Year. The contents of this blog do not represent views of entities or persons other than the author, who notes no conflict of interest.

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